Healthcare Provider Details

I. General information

NPI: 1447554316
Provider Name (Legal Business Name): ST. GABRIEL'S, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/06/2011
Last Update Date: 03/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3137 32ND AVE S SUITE 223
FARGO ND
58103-6159
US

IV. Provider business mailing address

3137 32ND AVE S SUITE 223
FARGO ND
58103-6159
US

V. Phone/Fax

Practice location:
  • Phone: 701-225-6408
  • Fax:
Mailing address:
  • Phone: 701-225-6408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QM0850X
TaxonomyAdult Mental Health Clinic/Center
License Number7174
License Number StateND
# 2
Primary TaxonomyY
Taxonomy Code261QM0855X
TaxonomyAdolescent and Children Mental Health Clinic/Center
License Number7174
License Number StateND

VIII. Authorized Official

Name: DR. EMMET MICHAEL KENNEY JR.
Title or Position: PRESIDENT
Credential: M.D.
Phone: 701-225-6408